Dystonic Hand Associated with Spontaneous Migration of a Retained Bullet

Case Report: Bilateral Deep Brain Stimulation Implantation on Different Targets for a Parkinson's Disease Patient With a Bullet in the Brain

Patients requiring deep brain stimulation due to intracerebral metallic foreign substances have not been reported elsewhere in the world. Additionally, the long-term effects of metallic foreign bodies on deep brain stimulation (DBS) are unknown. A 79-year-old man with a 5-year history of Parkinson's disease (PD) reported that, 40 years ago, while playing with a pistol, a metallic bullet was accidentally discharged into the left brain through the edge of the left eye, causing no discomfort other than blurry vision in the left eye. DBS was performed due to the short duration of efficacy for oral medication. Because the bullet was on the left subthalamic nucleus (STN) electrode trajectory and the patient's right limb was primarily stiff, the patient received globus pallidus interna (GPi)-DBS implantation in the left hemisphere and STN-DBS implantation in the right hemisphere. During a 6-month postoperative follow-up, the patient's PD symptoms were effectively managed with no noticeable discomfort.

Patient with Hemiparkinsonism Secondary to a Gun Pellet in the Contralateral Substantia Nigra

A 33 year-old male presented with right upper limb rest tremor that disappeared on action, posture associated with bradykinesia, and rigidity of right upper and lower limbs (Video S1). Patient also presented right-sided pyramidal weakness (grade 4), hyperreflexia, extensor plantar response, and hemihypesthesia. Skull X-ray and computed tomography (CT) of the brain showed several metal pellets producing multiple artifacts (Fig. 1A,B). Only one pellet settled in brain parenchyma (left midbrain), while other pellets settled in the skull bone (Fig. 1A). Transcranial sonography (TCS) was performed, confirming that the midbrain pellet was placed within the left substantia nigra (Fig. 1C). Levodopa challenge test was conducted, showing no improvement (pre- and post-l-dopa motor UPDRS were 21 and 20, respectively). A further chronic trial of l-dopa (for 3 months) also proved negative. Biperiden and propranolol were also tried with negative results. Figure 1Computed tomography (CT) of the brain and X-ray skull showed several pellets that produced multiple streak artifacts (Fig. 1A,B). Only one pellet rested in the brain parenchyma, the left (contralateral) midbrain as detected by CT (Fig. 1A), and transcranial sonography (Esaote MyLab Five, Providian, Italy) via temporal window (Fig. 1C). Abbreviations: SN, substantia nigra.Hemiparkinsonism has been previously reported secondary to midbrain lesions.1, 2 To the best of our knowledge, movement disorders (secondary to brain injuries) related to bullet fragments have been scantly reported. In one reported case, hemiparkinsonism and dystonia were the result of a bullet in midbrain,2 and in another, dystonia was caused by a bullet in internal capsule.3.